- Author: Elliot Stieglitz, MD; Chief Editor: Emmanuel C Besa, MD more...
Steps in therapeutic plasma exchange
The following is an example of the steps involved in performing therapeutic plasma exchange using centrifugation-based equipment such as the Spectra Auto PBSC:
Any heparin that may be present in each of the two lumens of a central venous catheter is removed
A waste of 3 mL is then discarded
Laboratory studies, including complete blood count (CBC), calcium, and fibrinogen, are ordered and specimens sent from the draw lumen
A flush with 10 mL of normal saline is placed in the draw lumen
The draw and return lumens are then connected to the tubing, which is previously primed with normal saline; however, if a patient weighs less than 20 kg, then the draw and return tubing is primed with packed red blood cells (RBCs) instead of normal saline
Height and weight are then entered into the system to allow estimation of total blood volume (TBV)
Plasma volume is then calculated as follows: TBV × (1 – hematocrit)
A replacement product is chosen
The total volume of the desired replacement product is entered—usually either 1 plasma volume (40 mL/kg) or 1.5 plasma volume (60 mL/kg)
A centrifuge speed is determined by the software on the basis of the data entered
The device then draws whole blood through the draw lumen to the centrifuge
Plasma is separated by the centrifuge and collected for discard
RBCs are also separated by the centrifuge, then returned to the patient along with the previously selected colloid of either albumin or fresh frozen plasma (FFP)
After the desired amount of plasma is removed, the machine is disconnected from the patient, and heparin is instilled into each catheter lumen to prevent clotting until the lumen is accessed again
A post–plasma exchange fibrinogen level is checked if albumin was used as the replacement product (albumin does not contain fibrinogen, as opposed to FFP) to assess whether the patient has become severely hypofibrinogenemic
Options for replacement fluid during plasma exchange include albumin, electrolyte solutions, hydroxyethyl starch, FFP, and purified protein products such as individual clotting factors or antithrombin III. Deciding which replacement product to use is based on the underlying condition and the risks and benefits associated with each replacement product. In general, albumin is the most common replacement product because of its low side-effect profile and broad availability.
If signs of hypocalcemia are present, replacement calcium can be administered either intravenously or orally. Additionally, the whole blood–to–citrate ratio can be titrated to minimize hypocalcemic symptoms, which are usually related to the amount of citrate being used as an anticoagulant.
If signs of hypomagnesemia are present, replacement magnesium can be administered intravenously.
If signs of general discomfort are present, the return rate can be adjusted downward.
If signs of hypotension are present, normal saline boluses can be administered.
If signs of a transfusion reaction are present, the product infusion is discontinued, and diphenhydramine and hydrocortisone are given. In cases of anaphylaxis or respiratory distress, epinephrine can be administered as well.
Special considerations in pediatric patients
Magnesium is not always given prophylactically, though the decision is physician-dependent.
If a patient weighs less than 20 kg, the draw and return tubing are primed with packed RBCs instead of normal saline.
Return rates of blood product are on the order of 1.5 mL/kg/min, as opposed to the standard 70 mL/min flat rate used in adults.
Patients can experience symptoms of hypocalcemia and or hypomagnesemia during and after the procedure and can be treated with replacement calcium and magnesium, respectively.
Patients frequently become hypothermic during the procedure, in which case they should be warmed appropriately.
Patients can experience transfusion-related reactions, in particular with FFP, and should be treated with diphenhydramine, hydrocortisone, and/or epinephrine depending on the severity of the reaction. These reactions can occur during and after the transfusion.
Patients can experience hypotension as a result of rapid fluid shifts, and proper precautions should be taken to minimize complications such as unintended falls.
Patients can become thrombocytopenic and hypofibrinogenemic after plasmapheresis (especially if albumin is being used as a replacement product) and should be monitored for signs of bleeding.
[Guideline] Kaplan AA. Therapeutic plasma exchange: core curriculum 2008. Am J Kidney Dis. 2008 Dec. 52(6):1180-96. [Medline].
Szczepiorkowski ZM, Winters JL, Bandarenko N, Kim HC, Linenberger ML, Marques MB, et al. Guidelines on the use of therapeutic apheresis in clinical practice--evidence-based approach from the Apheresis Applications Committee of the American Society for Apheresis. J Clin Apher. 2010. 25(3):83-177. [Medline].
Siami GA, Siami FS. Membrane plasmapheresis in the United States: a review over the last 20 years. Ther Apher. 2001 Aug. 5(4):315-20. [Medline].
Gerhardt RE, Ntoso KA, Koethe JD, Lodge S, Wolf CJ. Acute plasma separation with hemodialysis equipment. J Am Soc Nephrol. 1992 Mar. 2(9):1455-8. [Medline].
Gurland HJ, Lysaght MJ, Samtleben W, Schmidt B. A comparison of centrifugal and membrane-based apheresis formats. Int J Artif Organs. 1984 Jan. 7(1):35-8. [Medline].
Agishi T, Kaneko I, Hasuo Y, Hayasaka Y, Sanaka T, Ota K, et al. Double filtration plasmapheresis. 1980. Ther Apher. 2000 Feb. 4(1):29-33. [Medline].
Siami GA, Siami FS. Current topics on cryofiltration technologies. Ther Apher. 2001 Aug. 5(4):283-6. [Medline].
Pham HP, Schwartz J, Cooling L, Hofmann JC, Kim HC, Morgan S, et al. Report of the ASFA apheresis registry study on Wilson's disease. J Clin Apher. 2015 Aug 14. [Medline].
Chang CT, Tsai TY, Liao HY, Chang CM, Jheng JS, Huang WH, et al. Double Filtration Plasma Apheresis Shortens Hospital Admission Duration of Patients With Severe Hypertriglyceridemia-Associated Acute Pancreatitis. Pancreas. 2015 Oct 21. [Medline].
McLeod BC, Sniecinski I, Ciavarella D, Owen H, Price TH, Randels MJ, et al. Frequency of immediate adverse effects associated with therapeutic apheresis. Transfusion. 1999 Mar. 39(3):282-8. [Medline].
Apter AJ, Kaplan AA. An approach to immunologic reactions associated with plasma exchange. J Allergy Clin Immunol. 1992 Jul. 90(1):119-24. [Medline].
McLeod BC. Therapeutic apheresis: use of human serum albumin, fresh frozen plasma and cryosupernatant plasma in therapeutic plasma exchange. Best Pract Res Clin Haematol. 2006. 19(1):157-67. [Medline].
Silberstein LE, Naryshkin S, Haddad JJ, Strauss JF 3rd. Calcium homeostasis during therapeutic plasma exchange. Transfusion. 1986 Mar-Apr. 26(2):151-5. [Medline].
Krishnan RG, Coulthard MG. Minimising changes in plasma calcium and magnesium concentrations during plasmapheresis. Pediatr Nephrol. 2007 Oct. 22(10):1763-6. [Medline].
Goldstein SL. Therapeutic Apheresis in Children: Special Considerations. Semin Dial. 2012 Jan 25. [Medline].
Mokrzycki MH, Kaplan AA. Therapeutic plasma exchange: complications and management. Am J Kidney Dis. 1994 Jun. 23(6):817-27. [Medline].
Galgiani JN, Catanzaro A, Cloud GA, Johnson RH, Williams PL, Mirels LF. Comparison of oral fluconazole and itraconazole for progressive, nonmeningeal coccidioidomycosis. A randomized, double-blind trial. Mycoses Study Group. Ann Intern Med. 2000 Nov 7. 133(9):676-86. [Medline].
McLeod BC. Introduction to the third special issue: clinical applications of therapeutic apheresis. J Clin Apher. 2000. 15(1-2):1-5. [Medline].
Sawada K, Malchesky PS, Nosé Y. Available removal systems: state of the art. Curr Stud Hematol Blood Transfus. 1990. 51-113. [Medline].
Suzuki M, Yamane S, Matsugane T, Nobuto T, Azuma N, Nishide T. Evaluation of double filtration plasmapheresis, thermofiltration, and low-density lipoprotein adsorptive methods by crossover test in the treatment of familial hypercholesterolemia patients. Artif Organs. 1996 Apr. 20(4):296-302. [Medline].